Longitudinal changes of mental health problems in children and adolescents treated in a primary care-based health-coaching programme – results of the PrimA-QuO cohort study

Background In Germany, 19.1% of boys and 14.5% of girls are affected by mental health problems (MHP). Paediatricians are usually the first in line to be contacted but they often do not feel adequately trained to diagnose and treat MHP in primary care. A major statutory health insurance fund introduced a health coaching (HC) programme to strengthen primary care consultation for MHP. The HC includes a training concept for paediatricians, standardised guidelines for actions and additional payments. The aim of this study was to investigate the potential effects of the HC programme on the change of MHP in children and adolescents. Methods A prospective cohort study was conducted in Bavaria, Germany, in 2018 and 2019. Data were collected at 2 points 1 year apart using an online questionnaire. Parents of patients with developmental disorder of speech and language, head/abdominal pain, conduct disorder or non-organic enuresis were approached by their health insurance. Families treated according to the HC programme form the intervention group while all others serve as controls. MHP was assessed using the Strengths and Difficulties Questionnaire (SDQ) as a child self-assessment (SDQ-S)/or external assessment by parents (SDQ-P). Determinants of SDQ total score were analysed using linear mixed effects models. Results Cross-sectional (n = 1090) and longitudinal analyses (n = 599) were performed. At baseline, a total of 23.5% had an SDQ total score “at risk” (SDQ-S > 15/SDQ-P > 13). There were no significant differences between intervention and controls. After full adjustment for all potential confounders, higher SDQ scores indicating more problems were significantly associated with male sex (2.000, p < 0.001) whereas a high parental education level was significantly associated with decreased SDQ scores (-2.127, p =0.034). There was a significant improvement in the control group over time (-0.814, p = 0.001) while the SDQ scores in the intervention group remained stable (-0.012, p = 0.020). Conclusion This evaluation of the HC programme could not prove a clinically relevant intervention’s effect on the MHP developmental course. Nevertheless, (HC) paediatricians have crucial potential to improve the care of MHP patients. Targeting families with less access to support measures might help reduce the burden of MHP and be a step towards continuous improvement of care. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01780-1.

The HC is predominantly implemented in Bavaria, one of the largest federal states of Germany with a total of 13 million inhabitants. The HC has been available nationwide since October 2015. More than 700 paediatricians in Bavaria and more than 2.100 ones nationwide are currently qualified to participate in the HC programme and approximately 36.000 children with MHP have been treated accordingly to the programme. Paediatricians play a central role in this context. The aim of the patient education is to impart self-management skills to the children and their parents and purposefully inform them about the various care services available. The HC includes a training concept for paediatricians based on a dual training participation, standardised action guidelines for 16 MHP (e. g. developmental disorder of speech and language, enuresis, head and abdominal pain) and additional fees for paediatricians who undergo this specific training and demonstrably act according to the guidelines [1].
With the HC, 15 euros per 10 minutes up to a cap of 180 minutes per child in addition to the statutory standard care are billable. The basic programme's principles are participation, patient orientation and strengthening of existing resources. The social-paediatric diagnostic is divided into 3 steps as shown in Typically, abnormalities are noticed at the developmental check-ups, by the parents themselves or at kindergarten/school. In a second step, the paediatrician carries out a detailed examination. Usually, a therapy alliance for 6 months is arranged with the parents, assessing the family's resources.
If the problems are too serious or the HC programme does not work, a referral to specialised care takes place. In this sense, children with minor problems can remain in the care of the paediatrician while resources are available for others who need immediate referral to specialised care (e.g., therapists, social paediatric centre). To implement the programme, it is necessary that the paediatrician participates in the SK programme and has completed the HC training participation and the child is enrolled in the SK programme so that HC services are billable.

Children and adolescents with mental health problems and their parents
Inclusion criteria: • Children aged 0-17 years insured with a BKK that participates in the SK programme (prerequisite for querying the secondary data) and their parents  2) conduct problems (5 items) 3) hyperactivity/inattention (5 items) 4) peer relationship problems (5 items)

5) prosocial behaviour (5 items)
Each of the SDQ items is scored on a 3-point scale with 0 = not true, 1 = somewhat true and 2 = certainly true, giving a maximum score of 10 for each sub-scale. Higher scores indicate more serious problems, except for prosocial behaviour, where higher scores indicate more positive behaviour. Following the SDQ scoring guide, these scores have been scaled up pro-rata if at least 3 items were completed for the sub-scale. If 2 or less items were completed, the sub-scale (and hence, the total SDQ) was treated as missing or incomplete. The questions for each sub-scale are the same at each age, with exception of 2 questions: The conduct disorder sub-scale varies slightly for 3-year-olds, as 2 items on antisocial behaviour are replaced by items on oppositionality.

Supplementary
Conduct problems score 0-2 3 4-10 Hyperactivity score 0-5 6 7-10 Peer problems score 0-2 3 4-10 Prosocial score 6-10 5 0-4 Emotional problems score 0-5 6 7-10 Conduct problems score 0-3 4 5-10 Hyperactivity score 0-5 6 7-10 Peer problems score 0-3 4-5 6-10 Prosocial score 6-10 5 0-4 Impact score 0 1 2-10 In addition, the SDQ includes an impact supplement. When participants feel like having any emotional or behavioural difficulties (Variable: P102), additional questions follow. They concern duration (chronicity), suffering of the child to subjectively perceived social impairments in 4 areas of everyday life (at home, with friends, in the lessons at school/day care centre for preschool children, for leisure activities) and the impairment of the family. An impact score can be formed from the item "Difficulties upset or distress child" and the 4 items for everyday impairments are formed with the following scoring: 0= "not true, no, not at all", 1= "somewhat true, yes-minor, just a little" and 2= "certainly true, quite a lot". The items on overall distress and impairment can be summed to generate an impact score that ranges from 0 to 10 for parent-and self-report. An impact score of 2 or more points counts as conspicuous. At least 2 areas of life are impaired or in at least one area of life severe impairments due to mental health problems occur. Responses to the questions on chronicity and burden to others are not included in the impact score. When respondents negated the question if they feel like having any emotional or behavioural difficulties, they are not asked to complete the questions on resultant distress or impairment. In this case, the impact score is scored zero.
The SDQ follow-up versions include the 25 basic items and the impact question, but also 2 additional follow-up questions for use after an intervention (Has the intervention reduced any problems? Has the intervention helped in other ways, e.g. making the problems more bearable?).

SDQ: Generating scores in SAS
The SDQ scoring algorithm is based on 25 variables plus impact items for each questionnaire. The first letter of each variable name is 'p' for the parental SDQ version and 's' for the self-report SDQ assessment. After this first letter ('p' or 's'), the variable names are named as follows in the original scoring syntax e.g., "consid" is named as "psconsid" in the parental scores and "sconsid" in the selfassessment scores. If the first response category (not true, no, not at all) has been selected, this is coded as "0", the next response category (somewhat true, yes-minor, just a little) is coded as "1" and the last category is coded as "2" (certainly true, quite a lot). The impact assessment has another category "3" (a great deal, yes-severe difficulties").
The algorithm generates 6 scores.
Again, the first letter of each derived variable is 'p' for parent-based scores and 's' for self-reportbased scores e.g., "emotion" is named as "pemotion" in the parental syntax and "semotion" in the self-assessment.

END OF SCORING SYNTAX
Both, the parental (SDQ-P) and the self-assessment version (SDQ-S) were analysed separately. The data are shown in Supplementary Table 3. The overall change in SDQ-P between baseline and follow-up was -0.4 (SD 4.3, min -13.0, max: 15.0).

Supplementary Table 3: Change in the SDQ parental (SDQ-P) and self-assessment (SDQ-S) version during the follow-up
The overall change in SDQ-S was -1.2 (SD 4.8, min -13.0, max: 5.0). There was a slight decrease in SDQ-S scores in boys (HC: -2.8, SD 4.1; Control group:-2.2, SD 4.2), which was statistically not significant. There were no significant health-related or demographic differences as compared to participants with complete follow-up (FU) that could explain the drop-out from the study. However, participants with 2